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The Demise of Primary Care: A Diatribe From the Trenches

David D. Norenberg, MD
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Corresponding Author: David D. Norenberg, MD, Gundersen Lutheran Medical Center, 1900 South Avenue, La Crosse, WI 54601.

Ann Intern Med. 2009;150(10):725-726. doi:10.7326/0003-4819-150-10-200905190-00011
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Medical school graduates are avoiding primary care. The very aspects that once attracted students have been subverted. The breadth of practice that was once appealing has become the breadth of heavy-handed scrutiny, as politicians and business leaders have demanded quality—simplistically defined as dogmatic adherence to a standard. Individualized clinical judgment has been devalued; thinking has been replaced by algorithms. Practice guidelines have been usurped by pay-for-performance police, on patrol for deviations—not understanding that knowing and allowing for exceptions is the heart and soul of primary care. The coercive surveillance of “Quality Improvement” has become oppressive, making single organ–system specialties increasingly attractive (or at least more tolerable). Generalists are spending so much time proving they are good doctors, they don't have time to be good doctors. A remedy is suggested: a pilot project of volunteer salaried internists (more trusted, less audited) commissioned to our expandable national health care program, Medicare.





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The Demise of Primary Care: It's not just the money!
Posted on May 23, 2009
Dana Merrithew
Conflict of Interest: None Declared

The Perspective article on the Demise of Primary Care by Norenberg speaks loudly to the frustrations all us "old-time" Internists have felt increasingly over the past several decades. When my colleages and patients have asked me about the demise of primary care, my response like Nurenberg's is "it's not just the money." The real problem is the loss of autonomy and trust that we are capable of doing the right thing for our patients. Third parties, government, and health care reformers including the ACP fail to understand this fundamental issue. The answers are always more technology, i.e. EMR, more QA, more "team building", more prior authorization. Meanwhile the costs keep escalating, the quality keeps falling, and Internists cannot wait to retire.

I would like to challange the ACP to take up the gauntlet thrown down by Norenberg and fund a pilot project as described. I will boldly predict the result - improved patient and physician satisfaction, better care by any measure, and lower cost.

Thank you Dr. Norenberg for giving voice to this issue.

Conflict of Interest:

None declared

Posted on May 25, 2009
Armando V. Rodriguez
No Affiliation
Conflict of Interest: None Declared

Dr. Dr. Norenberg:

You've read my mind and my soul. Primary care is dying. Money is the root of all evil. Yes every barrel has a couple of spoiled apples. But, the majority of physicians went into medicine to help people through the art and science of medicine. I strongly believe in a single payor system (Medicare-for everyone, first to last day of life).

Get rid of the middle men (HMO< MSO and private insurance companies). Healthcare is a GOD given rite. Not to be determined who' entitles to receive healthcare. Wit what limitations. Business has destroyed the patient-physician relationship.

I highly consider that Dr. Norenberg's article should be submitted to be reviewed the President's Obama Health Reform Task Force in Washington. Our patients and elected officials in congress should read this article. Dr. Norenberg lets not loose hope. Medicine has never been perfect. 100 years ago doctors had to see their patients suffer and die from simple infectious diseases and surgical procedures complications. Patient ignorance and lack of education prevented many patients from seeking healthcare. Thanks to antimicrobials, antisepsis, better sanitation and public education we have been able to increase life span and save many lives. But, we have not been able to improve our conutries quality of life. Our society is out of control. Money has has been the benchmark for success for many people. I believe that as doctors we need to recommend that success is having a good quality of life. Not just focusing in physical health. But, offering mental health and spiritual advise. Encouraging our patients to have a life of moderation. Trying to work less on having a rich material life. Work more on enriching their relationship with themselves, God, family and their fellowman. Thrive for a good material life and a great-healthy personal and social life.

My end of life patients have taught me that in their final days and minutes of their lives what is menaingful and important to them are the experiences and relationships which they had or didn't have with their fellow man. My dying patients do not wish they could have made more money or belonged to a higher socioeconomical class.

I.m a 47 yr. old practicing general internist in Miami, Florida. I believe that says it all. I truly understand and stand by you. But, I hope that the next 3-5 years will bring positive changes in healthcare with the President Obama and a new federal government administration. Dr. Noremberg let's not lose hope. Internal medicine in our country has hit rock bottom. I believe that from now on things can only get better. Patience is a virtue.

Conflict of Interest:

None declared

The Gift of Primary Care
Posted on May 25, 2009
Judith M Brenner
NYU School of Medicine
Conflict of Interest: None Declared

I had just arrived home after a long day at work at Bellevue Hospital when a friend emailed me Dr. Norenberg's perspective piece. "Read this" the subject line said. My first reaction to "The Demise of Primary Care: A Diatribe From the Trenches" was complete identification. I quickly responded. His words were words we'd shared: thoughts about the frustration of caring for patients in 2009; the frustration of being judged against impossible standards; the ever present feeling of inadequacy in truly being able to address our patient's needs.

Later, I reflected on some of the changes that I've been faced with through my 10+ years practicing medicine. For me, the biggest change has been the number of patients I'm expected to see in a session"”a number that currently feels impossible in my largely non-English speaking, psychosocially complicated population. For my husband, also an internist, but who practices in a NY suburb, it's been "the intrusiveness of managed care". And earlier the same day, I chatted with a colleague about the infiltration of performance measures into the world of patient care. A while back, "performance measures" were welcome. They felt business-like and in the late 1990's and early 2000's when business was booming, it seemed logical to borrow best practices from our colleagues. However, as a physician, being faced with "report cards" has become truly demoralizing. Dr. Norenberg's statement: "The watchdogs figured out that quantifying quality was far less daunting when no exceptions were allowed." This is akin to a child's report card without an "effort" column. Johnny may have received a "B", but the "tries very hard" and being a "pleasure to have in class" has to count for something.

The next thought followed logically"”one I've had from time to time over the years: did I make the right choice? Would I have been happier in staying in the specialty I trained in"”for me, rheumatology? I'm not alone in being a specialist-turned-internist.

For me, the answer is so clear: no, no! I love what I do! The reason I switched and the reason I stay goes back to medical student days: internal medicine is totally fascinating. Call me crazy, but I'm one of those people who wakes up in the morning happy to go to work and comes home usually feeling drained, sometimes feeling frustrated, yet always proud to do what I do. For those of us who are in primary care and for those students who select it, there's simply no other choice: we need to think about a person as a whole and won't be satisfied thinking about a system at a time. The combination of variety of presentations, differential diagnosis, the thrill of making a diagnosis, and the satisfaction of helping a patient navigate an increasingly more complicated system is simply unmatched in any other specialty.

Dr. Norenberg addresses his concern about the students and "showing by their actions of avoidance" why "primary care is dying". To me, the students are "our children" and mentoring them, our greatest responsibility. How do we simultaneously convey our enthusiasm while being honest about the frustrations? That's the true challenge and one that's even more complicated as health care reform remains front page news. When speaking to students who are on the brink of entering their third year of med school, I say it simply: allow yourself to fall in love with a field and choose that field"”let emotion dictate over pure logic. Mentoring is more than just saying the words. For us, it needs to mean: lead by example and actively demonstrate what you still love about Medicine.

After reading Dr. Norenberg's piece, it feels like it's our colleagues who need mentoring, or at least a little pep talk. Remember, each day is a mystery that keeps us engaged. What's unique to our profession and something that will never change no matter what "the system" throws at us is this truth: wherever you turn, there's something interesting to learn about-something that inspires us to want to learn more. With every patient encounter, we have the opportunity to truly impact on someone's life. How many professions offer that? It's a gift and we need to appreciate that opportunity. And this is true despite the daily annoyances. What job doesn't have daily annoyances? What profession hasn't witnessed changes in the last 20 years? So, at the end of a long day, rather than recalling the frustrations, give yourself a moment to enjoy a sense of pride and allow yourself to wonder what the next day will bring.

Sincerely, Judith Brenner, MD Associate Program Director NYU Department of Internal Medicine Associate Editor, http://ClinicalCorrelations.org

Conflict of Interest:

None declared

Is quality improvement killing primary care?
Posted on May 25, 2009
Michael Hwa
Santa Clara Valley Medical Center
Conflict of Interest: None Declared

I read Dr. Norenberg's Perspective with great interest. I am currently finishing my chief residency at a county hospital, and in my four years here I have seen the decline in interest in primary care from the housestaff and the growing frustration of our primary care physicians.

I would disagree, however, with Dr. Norenberg's assertion that Quality Improvement (QI)has castrated the ability of primary care physicians to "be good doctors." During my internal medicine training, I've become very much interested in QI and how it can be used to supplement, not supplant clinical judgement. Clearly "cookie cutter" medicine serves in no one's best interest, and certain pay for permormance measures are based on spotty evidence at best. However, I believe in QI because I have seen first hand, even with my paucity of experience, the huge discrepancies in patient care that exist at all levels: from physician to physician and from hospital to hospital. Although "transparency" may be a trendy word these days, quality measures can be a way for us to re-evaluate our own practices, to have accountability for deficiencies in our care and to allow our patients to make more informed decisions about one facet of quality of care.

Primary care is facing dramatic challenges. As a profession it will need to adapt and evolve to attract new physicians and to re-invigorate those who already serve in this crucial field. I disagree with the author's assertion that QI has contributed to the waning interested in primary care. I strongly believe that quality improvement, administered in a thoughtful and evidence based manner, can help all physicians improve the care of their patients.

Conflict of Interest:

None declared

An Aleady Existing Option
Posted on May 29, 2009
Robert CJ Krasner
Clinical Professor of Medicine -New York University School of Medicine
Conflict of Interest: None Declared

Dear Dr Norenberg: I could not agree more with your excellent Perspective essay. I think there is a increasing need for the specialty of "consultant diagnostician" and that it will emerge as a most intellectually and emotionally stimulating field. As for your solution of a pilot project, perhaps the model you should consider is a civilian equivalent of the military internist. I thoroughly enjoyed my clinical career which took me from Boston to Ethiopia, Italy, London, Bethesda, Jakarta, San Francisco, and back to Washington with a few additional stops and prepared me for a second clinical career in New York City.

Conflict of Interest:

None declared

The bell is tolling
Posted on May 29, 2009
James P Morgan
St Barnabas Hospital
Conflict of Interest: None Declared

I precept primary care residents weekly. When asked, I will tell them to "find a niche. It's not enough to be in primary care. Primary care as we know it is dying." For example, economic forces are driving an increased demand for nurse practitioners to take over primary care, based on the false "marketing" notion that one or two yrs beyond an RN or BSN is the equivalent of seven or eight yrs of medical training. (Often patients don't know that they are seeing a NP, instead thinking they have just had an appointment with a doctor.) "Midlevel practioners" are seen as practically equally skilled as me by many payors.

It is disheartening to be reimbursed at a fraction what other specialties are despite treating patients who tend to be at least equally complicated. A successful colleague in my area solves this by seeing as many patients as is humanly possible each day, and consulting for anything but the most mundane problem. This take the fun out of medicine, but exceedingly low reimbursements take the fun out as well. Why should a urologist make two to three times what I do in one year?

The chart note has become the equivalent of the procedure, as internists make sure that higher level visits are fully documented. This is crazy. The medical chart has become billing centered rather than patient centered.

I applaud Dr Norenberg for his suggested way to address the situation. It shows creativity and flexibility. The model is not unlike that at many public hospitals, with salaried phsyicians. It is worth exploring.

Conflict of Interest:

None declared

A Hearty "Second!" for A Diatribe From the Trenches
Posted on June 4, 2009
Rick Frieden
Lakeland Regional Health System
Conflict of Interest: None Declared

I was most gratified to read Dr Norenberg's wonderful diatribe. Yes, he may - as he says - be a cynical curmudgeon, but he has hit the nail square on the head, and managed to bury it to the head with a single thwack from his hammer. He has given voice most eloquently to what I have seen so clearly and have been straining to say (but not managing to say nearly so succinctly or effectively) since I was a resident in Neurology and Internal Medicine.

His diagnosis is exactly correct, and explains why I have become a salaried, hospital-based neurologist rather than open a practice. I want to be as free as possible from the constraints imposed upon my practice by nonmedical "experts" who think everything about patient care can be reduced to a supposedly evidence based "best practice" algorithm. There ARE too many exceptions, and they DO matter. That is why our profession will always be at least as much an art as a science, and takes so long to learn.

I agree with his prescription, too, as long as it is implemented more or less as prescribed, with a minimum of interference from nonmedical bureaucrats and (probably well-intentioned) pencil-pushers and bean counters. In fact, I would probably enthusiastically seek out just such a position, were one available near where I live.

I would hope that someone will see that copies of this excellent editorial get handed to each and every member of congress in both the House and the Senate, as well as sent by the truckload to CMS and JCHO.

Conflict of Interest:

None declared

Theat of malpractice, a big contributor to the demise of primary care
Posted on June 5, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

I agree with most of Dr. Norenberg's ideas. Indeed many primary care doctors suffer from devalued individualized clinical judgment. Clinical guidelines have gotten the upper hand and if they are not returned to their original purpose of being suggestions not mandates, then Dr. Norenberg's comment that perhaps primary care doctors could be trained in technical schools along with refrigerator repairmen may become a reality. We may even be closer than we like to admit.

He did not mention however, that like the guidelines he aptly criticizes, the ever-present threat of malpractice suits(intensified by the wide spectrum of symptoms and other demands placed that these doctors are faced with) and the misery they bring are as great a deterrent to new doctors as is the "devaluation of individualized clinical judgment" he decries.

Although from time to time the results of questionnaires of primary care physicians' levels of job satisfaction are published I have never seen one that conveys truthfully the disgust that most doctors feel about the malpractice issue. I am sure that in their personal conversations most primary care doctors are much freer with their thoughts making this a major issue that turns doctors away from primay care.

My point is that the plight of primary care is even worse than that described by Dr. Norenberg. His idea of a pilot project with doctors working for a fixed salary might be worth trying but without a change in the malpractice climate the results will be incomplete and misleading.

Conflict of Interest:

None declared

The "Gift" of primary care gets smaller every year
Posted on June 5, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

Dr. Judith M. Brenner's enthusiasm and cheerfulness in the face of the many annoyances that pollute primary care doctors' professionalism and job satisfaction are admirable (rapid response, "The gift of primary care"). She urges doctors, despite the many aggravations that buffet their daily lives, to search for and enjoy the satisfaction that she finds at the end of a day. We need her type in medicine as a model to uplift our spirits when we are overflowing with negativity and questioning why we chose primary care.

But to bring about the changes that are necessary to improve physicians' lives and protect their integrity it is necessary to admire and hold up as models also those who are dissatisfied enough to participate in the political struggle to restore medicine's rightful professionalism.

Remaining cheerful and optimistic are important but remaining dissatisfied and committed and persevering to protect medicine and willing to confront the forces that are aligned against it must never be understated. The danger is that it may lead to indifference and a denial of the hostile forces that are desirous of controlling medicine.

They too are cheerful and optimistic about the future and what tomorrow will bring. But for them what tomorrow will bring bodes poorly for all doctors.

Conflict of Interest:

None declared

Posted on June 9, 2009
Claus Petermann
Private Practice
Conflict of Interest: None Declared

Doctor Norenberg:

Congratulations for the extremely well written article about the demise of primary care published in the Annals. My first love is still Internal Medicine and at age 81, I am still practicing full time in my office and hospital. I am also teaching Medical Student and none of them are interested in going into Internal Medicine or other primary care. The money just simply is not there to repay student loans once they enter the medical practice.

It breaks my heart that Internal Medicine, once the most important and interesting specialty, is now being held in so little regard. The Internist once upon a time was the battlefield commander of the medical field making the important decisions on how to defeat the enemy, and making a patient well again. It takes more than cookbook medicine, guidelines, and algorithms to take care of the individual patient. It takes the Art of Medicine to accomplish that, and it is a sorry state of affairs that the Art of Medicine has become so unattractive. The main reason, of course, is the poor reimbursement and the creation of more and more subspecialties which make alot more money compared to a poor Internist.

Will it take an act of Congress to address this problem? Should there be hearings to prevent a serious shortage of well trained Internists, family physicians, and Pediatricians? Could the entire field of Medicine be handled by just subspecialists?

I made copies of your article and gave them to all of my colleagues, and also my patients.

Please continue the Diatribe from the Trenches so the country might eventually hear us!

With warmest regards and appreciation,

Claus Petermann, MD, FACP

Conflict of Interest:

None declared

Lets Focus
Posted on June 11, 2009
rodrigo baltodano
No Affiliation
Conflict of Interest: None Declared

Dear Dr. Noremberg,

You have written the quintessential article regarding the main cause of the demise of Primary care. By virtue of the detached attempts at dehumanizing and depersonalizing this critical specialty those who advocate what they believe is a solution are actually condemning it into oblivion. The most profound and motivating aspects of this craft are being ignored while the least appealing and most pragmatic are being touted. Whether intentionally or unintentionally, those who are charged with the ability to change the face of this practice for the benefit of the economy and, hence, the public itself, are too far removed from the ranks that should and ought to be at the head of effecting the change.

I have been in practice for 5 years since completing my residency in Internal Medicine at Washington Hospital Center/Georgetown University. My father, a nephrologist who now only practices Internal Medicine, and I are among the only 4 physicians in one of the largest suburbs of Orlando who still see inpatients and who still operate strictly without the use of nurse practitioners or a physician assistant. We do not advertise and yet we are sought after for the simple reason that we do what internists were trained to do: we see patients personally as outpatients, we see them personally as inpatients, and we don't make exceptions,

I have read all of the responses in this forum and there are only one or two from my generational peers, this speaks volumes about the nature of this problem. Further, I sense a feeling of agreement, but in the direction of surrender. Ironically, nowhere in any of the admittedly unrealistic and dysfunctional solutions proposed by the government is there a desire to annihilate this specialty. In fact, the opposite is true. Rather than throwing in the towel we need to organize as physicians and come up with solutions to this problem and make them heard. I for one intend to approach my local ACP chapter to energize this issue in any way that I can.

Although Dr. Noremberg's pilot project is an elegant one it is not practical for the simple reason that most physicians are in private practice and being a part of it would condemn their practices to closure. Further, any government program would be intrinsically defective because it would by definition institute algorithmic medicine as the first, second, and third measure of efficiency. The main problem behind the primary care crisis is that it is not understood elementally. We need more internists. That is all. We need to understand clearly the various reasons why there are so few young physicians choosing it and remedy these. In this day and age, where the younger the generation the more impulsive, superficial, and valueless it generally is, the more sensitive it becomes to marketing. Wasn't it Hannibal that said "focus on opportunities rather than problems"? Internal medicine needs to be marketed to residents and, in turn, to medical students.

I will be sending Dr. Noremberg a copy of my essay discussing this. And if anyone is interested please email me for I would be happy to forward it to them both for feedback and dissemination.

Let's get organized. We can make a difference.

Conflict of Interest:

None declared

A Last Cry from a General Internist
Posted on June 19, 2009
Howard A. Miller
Drexel University College of Medicine
Conflict of Interest: None Declared

As a general internist, last month's article by Dr. Norenberg certainly echoed my feelings about the impending demise of my chosen profession. While I still love the field of General Internal Medicine, it is disheartening to see how external forces are decimating this critical specialty. Our poetic catharsis was penned as a response to the new world:

What I Used to Be

I used to be a General Internist Now I'm a primary care doctor.

I used to be called a primary care doctor. Now I'm called a provider.

I used to refer patients to subspecialists. Now I write referrals to subspecialits.

I used to care for my patients in the hospital. Now I abdicate care to a hospitalist.

I used to maintain continuity of care. Now I live in a fragmented care world.

I used to order tests to confirm a diagnosis. Now I order tests to avoid lawsuits.

I used to order radiology procedures Now I precertify radiology procedures.

I used to train general internists. Now I train gastroenterologists and cardiologists.

I used to make decisions solely based or patients' needs. Now I make decisions based on insurance rules.

I used to love my profession. Now I have a job.

Conflict of Interest:

None declared

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